Director, Quality Management

Overview

Approximate Pay Range: $138,100 - $200,000/year. Eligible for an in-state or out-of-state relocation bonus.

Employer: St. Charles Health System

Job Title: Director of Quality Management

Reports To: Chief Nurse Executive/Chief Clinical Officer

Department: Quality Management

Date Last Reviewed: October 2025

Our Vision: Creating Americas healthiest community, together

Our Mission: In the spirit of love and compassion, better health, better care, better value

Our Values: Accountability, Caring Teamwork and Safety

The Quality Management (QM) department provides essential services to St. Charles Health System (SCHS) across the continuum of care, including quality improvement expertise and support; data analysis and reporting; regulatory affairs, accreditation and licensing expertise, maintain infection prevention and control; support; emergency preparedness; policy and document library management and support.

The Director of Quality Management provides oversight and direction to the SCHS quality and safety programs to achieve clinical quality performance improvement, mortality review and reduction, quality assessments, quality data analysis and reporting (including external quality reporting and clinical registries for benchmarking and reporting). This leader oversees regulatory compliance, accreditation status, and infection prevention. Collaborates with Risk Management & Patient Safety, and Environment of Care to improve and maintain a safe environment for patients and caregivers.

This role supports clinical care and support functions to enhance safety and experience for patients, families, caregivers, and the organization. This position manages caregivers in the Quality Management Department.

• Partners with campus executive leadership teams and departments to ensure that the quality and safety programs effectively measure, assess, and continuously improve the care and safety of services provided.
• Serves as a key partner for Nursing, Medical Staff, and administrative leaders to achieve System Quality Key Performance Indicators (KPIs) and advance the vision for clinical excellence and the effective use of resources through continuous quality improvement.
• In collaboration with executive leadership, sets goals and strategic direction for units within the QM department and oversees work products for Regulatory Affairs, Accreditation, & Safety, Quality Data, Quality Improvement, Infection Prevention. Develops, implements, and monitors the QM annual plan and budgets toward achieving System Quality KPIs. Assists and collaborates with local leadership at each site to create written quality assurance improvement plans (QAPI) on a yearly basis.
  
  Contributes to ongoing monitoring of the plan and progress toward goals.
• Promotes a Culture of Excellence and non-punitive response to reporting.
• Keeps up to date with new and revised state and federal statutes, regulations, and accreditation policies related to patient care. Reviews and evaluates related policies and procedures and recommends revisions as needed. Creates for approval new policies as needed.
• Proactively evaluates areas of organizational clinical quality based on internal assessment and external benchmarking;
  Clinical Quality Data Analytics and Reporting and implements strategies and policies which promote evidence-based care.
• Oversees Infection Prevention and Control Plan; maintains annual risk assessment and program plan; oversees Safety Audits and required regulatory audits for all levels of care.
• Prepares quality management reports for leadership with key performance indicators, strategies, and barriers to achieving targets and presents to Medical Executive Committee, Clinical Leadership Council and the Board Safety and Quality Committee.
• Advises Executive Leadership and Legal & Risk on issues impacting quality management and process improvement opportunities and initiatives.
• In coordination with Legal and Compliance, serves as liaison to external regulatory agencies for patient and physician reporting, event investigation and response (including Oregon Health Authority).
• Supports hospital executive teams to develop, implement, and monitor programs, policies, and procedures according to SCHS, OSHA, Joint Commission, local, state, and federal standards and statutes.
• Manages the organization s accreditation, regulation, and licensing activities by communicating programs and processes, preparing for reporting, surveys, and inspections, and by developing assessments, audits, and action plan responses (includes TJC, CMS, CLIA, OAR, OSHA, DPSST, etc.). Ensures SCHS policies and procedures are accurate, current, and consistent across the system.
• Collaborates with Business Intelligence, IT, hospital and clinic leadership, and medical staff leadership to ensure performance data is analyzed, communicated, and routinely provided to achieve System Quality KPIs.
• Engages and supports leadership in…